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Māori, New Zealand’s Indigenous population, experience lower rates of healthcare access and quality of care than non-Māori.[[1–5]] Treatment costs,[[1,2,5]] limited transport availability to health services[[1,5]] and other obstacles to attending appointments (e.g., no sick leave, availability of childcare)[[1,2,5]] are some of the barriers Māori face in accessing healthcare. Studies also reveal that Māori experience greater levels of racism and inappropriate care when they do present for treatment.[[6–9]] This, combined with poor communication from clinicians,[[1,2,10]] and a dearth of culturally safe health providers, can result in Māori disengaging from healthcare services or delaying seeking treatment,[[6,10,11]] likely contributing to why Māori have lower rates of access to services and support provided by the Accident Compensation Corporation (ACC), New Zealand’s universal no-fault injury insurer. Lodgement of claims for ACC support are made by health service providers on behalf of patients who present for treatment of an injury.[[12]]

ACC have long acknowledged that Māori have not benefited from their services to the same extent that non-Māori have, receiving ACC-funded support and entitlements at a lower rate than non-Māori.[[13,14]] An ACC Aide Memoir,[[15]] provided to the New Zealand Government’s Minister of ACC in May 2021 and obtained via an Official Information Act request, revealed that Māori are more likely to experience serious injuries, are less likely to lodge claims for non-serious injuries, and, alarmingly, are less likely to be referred for certain injury treatment interventions than non-Māori claimants.[[15]] This is consistent with other research that has found Māori experience lower quality of care in terms of less optimal treatment pathways and lower rates of referral to specialist treatment than non-Māori.[[2-4]] It may also help explain why Māori experience a greater prevalence of adverse injury outcomes than non-Māori,[[16]] even when having accessed ACC support.[[17,18]]

These experiences could have significant consequences when it comes to seeking treatment and support from ACC for subsequent injuries (SUBS-Inj), i.e., injuries that occur after, but not necessarily due to, an earlier “initial” (sentinel) injury. Subsequent injuries can be more costly financially and socially, and have greater consequences in terms of disability, than initial (sentinel) injuries.[[19–21]] Differential rates in accessing and receiving treatment and ACC support for SUBS-Inj could exacerbate the already concerning inequities in adverse injury outcomes between Māori and non-Māori. Therefore, the overall aim of this study was to investigate whether there were differences between Māori and non-Māori in claims made to ACC for SUBS-Inj, and compensation received, among a population who had already sustained a significant injury no more than 12 months earlier.

The Prospective Outcomes of Injury Study (POIS)[[22]] is a longitudinal study of people aged 18–64 years who sustained an injury warranting an ACC entitlement claim (i.e., earnings-related compensation, home help and/or travel assistance) between 2007–2009. Participants were interviewed, on average, 3, 12 and 24 months following their sentinel injury (i.e., the injury that led to their recruitment to the study). Nearly one-third (32%) of Māori compared to 28% of NZ Europeans self-reported sustaining a SUBS-Inj between 3 and 12 months after their sentinel injury.[[23]] The Subsequent Injury Study (SInS)[[24]] utilised ACC administrative data and found that 42% of Māori participants experienced at least one SUBS-Inj involving an ACC claim (ACC-SUBS-Inj) in the 12 months following their sentinel injury.[[25]] The prevalence in the total cohort was 38%.[[26]]

Utilising data obtained from POIS participants and administrative data obtained from the ACC, descriptive analyses were conducted to compare the following between Māori and non-Māori: 1) the proportion of participants who self-reported a SUBS-Inj between 3 and 12 months after their sentinel injury but who did not have a corresponding ACC claim for a SUBS-Inj (ACC-SUBS-Inj) during this period (including comparisons by socio-demographic variables and experiences of healthcare for their sentinel injury), 2) the severity of ACC-SUBS-Inj and the proportion that resulted in an entitlement claim, and 3) the percentage of ACC-SUBS-Inj claims that covered various treatments and supports, and the median amount of compensation provided by ACC. The analyses presented in this paper provide original findings to contribute to the limited evidence base about equity between Māori and non-Māori in terms of accessing and receiving ACC support for subsequent injuries, for those that have already received treatment and support from ACC for an earlier injury.

Methods

POIS participants were asked about their injury and recovery during interviews conducted primarily by telephone. Details explaining the recruitment of individuals and the collection of data have been published elsewhere.[[22]] Ethical approval for this study was obtained from the New Zealand Health and Disability Multi-Region Ethics Committee (MEC/07/07/093).

At the 12-month POIS interview, participants were asked: “Since we last spoke about 8 months ago, have you had any other (new) injuries? That is, injuries that have occurred as the result of a separate incident from the original injury.” These included injuries of any type or anatomical site. For the 12-month period following their sentinel injury, ACC injury compensation claims data inclusive of all claim types (i.e., not just entitlement claims) were obtained for all POIS participants (data received from ACC in 2013). The reference period for self-reported SUBS-Inj was between the 3- and 12-month interviews (following the sentinel injury). The ACC claims data about SUBS-Inj used in this study was selected to correspond to that same period.

Chi-squared tests were conducted to compare the socio-demographic and injury-related characteristics (of both sentinel and SUBS-Inj) between Māori and non-Māori participants. Ethnicity information was collected at each POIS interview using the 2006 New Zealand Census ethnicity question.[[27]] Māori participants were those who reported Māori ethnicity at either of the interviews, regardless of additional ethnicities they may have also reported.

Equality of proportions tests (Two-Sample t-Test of proportions) were conducted to compare, by selected socio-demographic and sentinel injury-related characteristics, the proportion of Māori and non-Māori participants who self-reported a SUBS-Inj at their 12-month interview but had no ACC claim recorded in the period between their 3- and 12-month interviews. Variables of interest included participants’ occupation and adequacy of household income prior to sentinel injury. This information was obtained during the first POIS interview using questions from the 2006 New Zealand Census[[27]] and 2006/2007 Household Economic Survey[[28]] respectively. Level of socio-economic deprivation, based on the New Zealand Index of Deprivation 2006 (NZDep06),[[29]] severity of the sentinel injury, as measured by the New Injury Severity Score (NISS),[[30]] whether or not participants had trouble accessing healthcare for their sentinel injury (Yes: yes/mixed; No: no) and experience of treatment for this injury (Good: very good/good; Not good: moderate/bad/very bad) were also examined.

Finally, Two-Sample t-Tests of proportions were used to compare the percentage of Māori and non-Māori ACC claims that covered various injury treatments and support. Two-Sample Wilcoxon Rank-Sum Tests were used to compare the median amount of compensation paid by ACC for Māori and non-Māori claims for each of these. All statistical analyses were conducted using Stata v13.1.[[31]]

Results

Of the 2,208 POIS participants who completed the 12-month interview and responded to the subsequent injury question, two did not provide ethnicity information, leaving data from 2,206 participants for the current analyses (Figure 1). Just under one-fifth (18%; n=397) of these participants were Māori.

View Figure 1 & Tables 1–4.

Characteristics of the cohort

A greater proportion of Māori participants were male compared to non-Māori (Table 1). Māori participants were also younger, on average, than non-Māori. There was no difference in the distribution of sentinel injury severity or hospitalisation status for sentinel injury between Māori and non-Māori participants.

Subsequent injuries

Over one-quarter (29%) of participants self-reported a SUBS-Inj between the 3- and 12-month interviews. There was some evidence that suggested the prevalence of self-reported SUBS-Inj was higher for Māori than non-Māori (Table 2). This was also apparent in the ACC claims data, with 37% of Māori having ≥1 ACC-SUBS-Inj compared to 32% of non-Māori. A total of 943 ACC-SUBS-Inj claims were made by these 731 individuals (Figure 1). The distribution in the severity (NISS) of these SUBS-Injs resulting in an ACC claim did not differ between Māori and non-Māori and there was little evidence of a difference between the two groups in the prevalence of ACC-SUBS-Inj that resulted in entitlement claims.

Accessing ACC: Self-reported subsequent injuries and ACC-SUBS-Inj claims

Of the 636 participants who self-reported SUBS-Injs, 34% (n=219) did not have an ACC-SUBS-Inj between the 3- and 12-month interviews (Figure 1). Overall, 32% of Māori and 35% of non-Māori did not have an ACC-SUBS-Inj claim in this period (Table 3). Statistically significant differences were observed between Māori and non-Māori for sub-categories of only two of the independent variables, for which associations between key variables and this outcome were analysed. Of those in a trade or manual occupation, 34% of non-Māori with self-reported SUBS-Inj did not have an ACC-SUBS-Inj compared to 19% of Māori (p=0.03). The opposite was found for those with a sentinel injury NISS>6, where 53% of Māori with self-reported SI did not have an ACC-SI compared to 23% of non-Māori (p=0.02).

ACC compensation for subsequent injuries

The percentage of claims involving various transport and treatment-related compensation from ACC, and the median amounts received, are presented in Table 4. Of the 943 ACC-SUBS-Inj claims, 40 (4%) were not accepted by ACC and therefore are not included in the cost analyses. Absolute differences between the Māori and non-Māori cohorts in the percentage of ACC-SUBS-Inj claims covering a particular treatment or support varied by 6% or less across the categories examined. For the 190 Māori with an accepted ACC-SUBS-Inj claim, 71% had the costs of medical treatment for their injury paid by ACC compared to 65% of the 753 non-Māori with an accepted ACC-SUBS-Inj claim (p=0.1). The largest difference observed among entitlement claimants was for income compensation payments, with 84% of entitlement claims for Māori including income compensation compared to 72% of claims for non-Māori (p=0.2). Other notable differences were the proportions of claims that covered specialist consultations (Māori: 18.5%; non-Māori: 13.5%; p=0.09) and “other” treatments including dental, optometric, podiatrist, acupuncturist and pharmaceutical care (Māori: 11.1%; non-Māori: 16.3%; p=0.07).

The median amount of ACC compensation per ACC-SUBS-Inj claim was higher for Māori than non-Māori participants for six of the seven transport and treatment categories examined (Table 4). For specialist consultations, the median amount covered per claim was smaller for Māori (NZ$179) than non-Māori (NZ$201). The largest difference observed was for transport-related costs where the median amount covered per claim was NZ$46 greater for Māori than for non-Māori, but it should be noted that this only applied to a small number of participants in each cohort.

Discussion

Analyses found few significant differences between Māori and non-Māori in terms of treatment and support for SUBS-Injs compensated by ACC. While estimates suggest that SUBS-Inj (both self-reported and ACC), and ACC entitlement claims for SUBS-Inj, were more prevalent among Māori, there was insufficient evidence to indicate that these differences were statistically significant. There was weak evidence of a difference in compensation in two areas: the proportion of Māori ACC-SUBS-Inj claims receiving compensation for specialist consultations was greater than among non-Māori, while the opposite was found for “other” treatments. Potential reasons for these particular findings are unclear. There was no difference between Māori and non-Māori in the severity of ACC-SUBS-Inj sustained, and our previous research found no noticeable difference in the types of SUBS-Inj incurred between the Māori[[25]] and overall POIS cohorts[[26]] in the 24 months following their sentinel injury. However, without detailed information from participants on their SUBS-Inj, we do not know what the specific needs and support required were for Māori and non-Māori and if these differed in any way.

The two areas of difference between Māori and non-Māori were among those who reported a SUBS-Inj at the 12-month interview but made no ACC claim for a SUBS-Inj in the reference period of 3 to 12 months post-sentinel injury. Non-Māori in a trade or manual occupation who self-reported a SUBS-Inj were more likely to have no ACC-SUBS-Inj claim compared to Māori in a trade or manual occupation. Conversely, Māori with a more severe sentinel injury were more likely than non-Māori to have no ACC-SUBS-Inj claim despite self-reporting a SUBS-Inj. Again, there are no obvious explanations for these observed differences, thus we cannot rule out that these are spurious findings. Had work-related SUBS-Injs been more prevalent among non-Māori, then the greater prevalence with no ACC-SUBS-Inj could have been due to some of these individuals working at an ACC accredited organisation.[[32]] In these organisations, while an ACC form is still completed for work-related injuries, these are sent to the patient’s employer for them to administer and cover the costs of their employee’s treatment and rehabilitation. However, we have previously found no difference in the prevalence of work-related SUBS-Injs between Māori participants[[33]] and the overall cohort.[[34]] We have previously found differences between Māori and non-Māori in the prevalence of disability and problems with mobility at 12 months post-injury,[[17]] and the greatest prevalence of these outcomes is among those who had a more severe sentinel injury (i.e., NISS>6). A potential explanation for the greater absence of ACC claims among Māori who self-reported a SUBS-Inj after a more severe sentinel injury is that a greater proportion were still experiencing problems with mobility compared to non-Māori who self-reported a SUBS-Inj after a more severe sentinel injury. This may have dissuaded Māori from accessing treatment for their SUBS-Inj unless it was severe enough to impede their recovery further. This hypothesis is consistent with the understanding that Māori access fewer ACC injury and rehabilitation entitlements, particularly for less severe injuries, than non-Māori.[[13,15]]

Strengths of this study include having a cohort that sustained a broad range of injuries, in terms of both type and severity, across an array of contexts (e.g., work- and non-work-related), that did not necessarily result in hospitalisation. A particular focus was to provide relevant information about injury outcomes specifically for injured Māori. This has resulted in our study, to the best of our knowledge, comprising the largest group of an injured Indigenous population, enabling us to provide valuable insights into equity in healthcare access and treatment for SUBS-Inj between an Indigenous and non-Indigenous group. The ability to examine a wealth of longitudinal data leading up to the SUBS-Inj is a further strength, as is the ability to utilise detailed administrative data to gain further insights about access to SUBS-Inj support for every participant.

Nonetheless, this study has some limitations. While the number of Māori participants in the cohort is large in total, small numbers arise when examining differences within the cohort, and between Māori and non-Māori, across some variables of interest. A lack of statistical power may have contributed to insufficient evidence to detect a difference where a difference, in truth, exists. It also restricts our ability to conduct more complex multivariable analyses. The generalisability of our findings is also limited. Although our cohort experienced a broad array of injuries, it only includes individuals who had already accessed ACC support for an injury serious enough to warrant an entitlement claim. We still lack a detailed understanding of differences in access to initial treatment and support between Māori and non-Māori for injuries among the entire New Zealand population (i.e., including for those who did not access ACC support). Given ACC is a universal no-fault government-funded scheme, it is important that barriers to access for all injured Māori are better understood and addressed.

Our estimates of self-reported SUBS-Inj may be affected by measurement error (i.e., variation among participants as to what constitutes an injury), recall bias and attrition, but there is a dearth of evidence on which to judge the likelihood and extent of each, and how it may specifically impact our findings. We have no reason to believe the distribution of measurement error would differ between Māori and non-Māori and thus increase or decrease the differences observed in no ACC-SUBS-Inj claims following self-reported SUBS-Inj. The same is true for recall error. While there is some evidence to suggest that injury type and severity may affect recall,[[35]] we have previously found no substantial differences in the types of sentinel injuries sustained between Māori participants and the overall cohort, including those that might directly affect recall (e.g., intracranial injuries).[[25,26]] The severity of SUBS-Inj in this study also did not differ between Māori and non-Māori. An analysis of non-participation at the 12-month interview among the cohort found that males, younger participants and Māori were less likely to take part in this phase of POIS.[[36]] However, none of these factors (i.e., sex, age or ethnicity) were predictive of self-reporting a SUBS-Inj at the 12-months post-sentinel injury interview.[[23]]

Conclusions

Our findings provide for cautious optimism and support calls for stronger efforts to reduce barriers to accessing quality healthcare and support services for injured Māori. Subject to the limitations of our study outlined above, it appears that for those who have already accessed the ACC system—in this case, those who have received an entitlement claim—Māori and non-Māori generally received equitable compensation for SUBS-Inj. This is in terms of the percentage of accepted ACC-SUBS-Inj claims covering costs across each of the various treatment types, the percentage covering transport costs related to injury recovery and the average amount of compensation for each of these treatment and support categories. However, receiving ACC compensation for such services is only part of the story, especially in light of ACC’s Aide Memoire of May 2021 stating that Māori are less likely to benefit from the ACC scheme and are less likely to be referred for some specific treatment interventions than non-Māori.[[15]] Further research is required to determine if Māori and non-Māori are receiving equitable access and appropriate treatment for injuries regardless of injury type (i.e., sentinel or subsequent) or ACC claim type (e.g., medical fees only or entitlement claims) once entered into the health system. This study highlights two areas that warrant further attention in this regard: differences between Māori and non-Māori in the median amounts of ACC-SUBS-Inj costs for specialist consultations and “other” treatments. Are these differences, in truth, significant and, if so, why do they exist? Given Māori and non-Māori participants experienced subsequent injuries of similar types and severity, it would be concerning, for example, if Māori were not being referred to other health providers or receiving compensation for care that could further optimise their recovery (e.g., dental and/or pharmaceutical care). More detailed information on the specific needs of those injured is necessary. If the support required for subsequent injuries in truth differed between Māori and non-Māori, then similar levels of compensation would mean inequitable support relative to need. Ultimately, if New Zealand is to achieve a situation where no inequities exist between injured Māori and non-Māori, and for increased positive outcomes to be achieved for Māori, it is imperative to establish routine systems for collecting data about needs, treatment pathways and outcomes.

Summary

Abstract

Aim

To examine if differences exist between injured Māori and non-Māori in accessing and receiving support from the Accident Compensation Corporation (ACC) for treatment and rehabilitation of subsequent injuries.

Method

This cohort study utilised participants’ self-reported datafrom the Prospective Outcomes of Injury Study, and ACC claims data.

Results

Approximately one-third of Māori (32%) and non-Māori (35%)who self-reported a subsequent injury had no associated ACC claim. Statistically significant differences in this outcome (i.e., self-reported subsequent injury but no ACC claim) were found between Māori and non-Māori when comparing across occupation type and severity of participants’ sentinel injuries. Few differences were observed between Māori and non-Māori in the percentages of ACC claims accepted that compensated various treatments and supports; this was similar for average compensation amounts provided.

Conclusion

Māori and non-Māori who received support from ACC for a sentinel injury prior to sustaining another injury appear to have received equitable ACC compensation for the treatment and rehabilitation of the subsequent injury with two potential exceptions. Further research is needed to determine how generalisable these findings are. Establishing routine systems for collecting data about the support needed, treatment pathways and outcomes once accessing ACC support is vital to ensure positive and equitable injury outcomes for Māori.

Author Information

Emma H Wyeth: Associate Professor, Te Roopū Rakahau Hauora Māori a Kāi Tahu (Ngāi Tahu Māori Health Research Unit), University of Otago, Dunedin, New Zealand. Gabrielle Davie: Associate Professor, Injury Prevention Research Unit, Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand. Brett Maclennan: Senior Research Fellow, Te Roopū Rakahau Hauora Māori a Kāi Tahu (Ngāi Tahu Māori Health Research Unit), University of Otago, Dunedin, New Zealand. Michelle Lambert: Research Fellow, Te Roopū Rakahau Hauora Māori a Kāi Tahu (Ngāi Tahu Māori Health Research Unit), University of Otago, Dunedin, New Zealand. Helen Harcombe: Senior Lecturer, Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand. Trudy Sullivan: Associate Professor, Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand. Sarah Derrett: Professor, Te Roopū Rakahau Hauora Māori a Kāi Tahu (Ngāi Tahu Māori Health Research Unit), University of Otago, Dunedin, New Zealand.

Acknowledgements

The authors are grateful to the study participants for sharing their information with the research team and to the POIS interviewers for their role in collecting participant data. The study was funded by the Health Research Council of New Zealand (Project Grant 15/091).

Correspondence

Associate Professor Emma Wyeth: Te Roopū Rakahau Hauora Māori a Kāi Tahu (Ngāi Tahu Māori Health Research Unit) University of Otago, PO Box 56, Dunedin 9054, New Zealand.

Correspondence Email

emma.wyeth@otago.ac.nz

Competing Interests

Nil.

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Māori, New Zealand’s Indigenous population, experience lower rates of healthcare access and quality of care than non-Māori.[[1–5]] Treatment costs,[[1,2,5]] limited transport availability to health services[[1,5]] and other obstacles to attending appointments (e.g., no sick leave, availability of childcare)[[1,2,5]] are some of the barriers Māori face in accessing healthcare. Studies also reveal that Māori experience greater levels of racism and inappropriate care when they do present for treatment.[[6–9]] This, combined with poor communication from clinicians,[[1,2,10]] and a dearth of culturally safe health providers, can result in Māori disengaging from healthcare services or delaying seeking treatment,[[6,10,11]] likely contributing to why Māori have lower rates of access to services and support provided by the Accident Compensation Corporation (ACC), New Zealand’s universal no-fault injury insurer. Lodgement of claims for ACC support are made by health service providers on behalf of patients who present for treatment of an injury.[[12]]

ACC have long acknowledged that Māori have not benefited from their services to the same extent that non-Māori have, receiving ACC-funded support and entitlements at a lower rate than non-Māori.[[13,14]] An ACC Aide Memoir,[[15]] provided to the New Zealand Government’s Minister of ACC in May 2021 and obtained via an Official Information Act request, revealed that Māori are more likely to experience serious injuries, are less likely to lodge claims for non-serious injuries, and, alarmingly, are less likely to be referred for certain injury treatment interventions than non-Māori claimants.[[15]] This is consistent with other research that has found Māori experience lower quality of care in terms of less optimal treatment pathways and lower rates of referral to specialist treatment than non-Māori.[[2-4]] It may also help explain why Māori experience a greater prevalence of adverse injury outcomes than non-Māori,[[16]] even when having accessed ACC support.[[17,18]]

These experiences could have significant consequences when it comes to seeking treatment and support from ACC for subsequent injuries (SUBS-Inj), i.e., injuries that occur after, but not necessarily due to, an earlier “initial” (sentinel) injury. Subsequent injuries can be more costly financially and socially, and have greater consequences in terms of disability, than initial (sentinel) injuries.[[19–21]] Differential rates in accessing and receiving treatment and ACC support for SUBS-Inj could exacerbate the already concerning inequities in adverse injury outcomes between Māori and non-Māori. Therefore, the overall aim of this study was to investigate whether there were differences between Māori and non-Māori in claims made to ACC for SUBS-Inj, and compensation received, among a population who had already sustained a significant injury no more than 12 months earlier.

The Prospective Outcomes of Injury Study (POIS)[[22]] is a longitudinal study of people aged 18–64 years who sustained an injury warranting an ACC entitlement claim (i.e., earnings-related compensation, home help and/or travel assistance) between 2007–2009. Participants were interviewed, on average, 3, 12 and 24 months following their sentinel injury (i.e., the injury that led to their recruitment to the study). Nearly one-third (32%) of Māori compared to 28% of NZ Europeans self-reported sustaining a SUBS-Inj between 3 and 12 months after their sentinel injury.[[23]] The Subsequent Injury Study (SInS)[[24]] utilised ACC administrative data and found that 42% of Māori participants experienced at least one SUBS-Inj involving an ACC claim (ACC-SUBS-Inj) in the 12 months following their sentinel injury.[[25]] The prevalence in the total cohort was 38%.[[26]]

Utilising data obtained from POIS participants and administrative data obtained from the ACC, descriptive analyses were conducted to compare the following between Māori and non-Māori: 1) the proportion of participants who self-reported a SUBS-Inj between 3 and 12 months after their sentinel injury but who did not have a corresponding ACC claim for a SUBS-Inj (ACC-SUBS-Inj) during this period (including comparisons by socio-demographic variables and experiences of healthcare for their sentinel injury), 2) the severity of ACC-SUBS-Inj and the proportion that resulted in an entitlement claim, and 3) the percentage of ACC-SUBS-Inj claims that covered various treatments and supports, and the median amount of compensation provided by ACC. The analyses presented in this paper provide original findings to contribute to the limited evidence base about equity between Māori and non-Māori in terms of accessing and receiving ACC support for subsequent injuries, for those that have already received treatment and support from ACC for an earlier injury.

Methods

POIS participants were asked about their injury and recovery during interviews conducted primarily by telephone. Details explaining the recruitment of individuals and the collection of data have been published elsewhere.[[22]] Ethical approval for this study was obtained from the New Zealand Health and Disability Multi-Region Ethics Committee (MEC/07/07/093).

At the 12-month POIS interview, participants were asked: “Since we last spoke about 8 months ago, have you had any other (new) injuries? That is, injuries that have occurred as the result of a separate incident from the original injury.” These included injuries of any type or anatomical site. For the 12-month period following their sentinel injury, ACC injury compensation claims data inclusive of all claim types (i.e., not just entitlement claims) were obtained for all POIS participants (data received from ACC in 2013). The reference period for self-reported SUBS-Inj was between the 3- and 12-month interviews (following the sentinel injury). The ACC claims data about SUBS-Inj used in this study was selected to correspond to that same period.

Chi-squared tests were conducted to compare the socio-demographic and injury-related characteristics (of both sentinel and SUBS-Inj) between Māori and non-Māori participants. Ethnicity information was collected at each POIS interview using the 2006 New Zealand Census ethnicity question.[[27]] Māori participants were those who reported Māori ethnicity at either of the interviews, regardless of additional ethnicities they may have also reported.

Equality of proportions tests (Two-Sample t-Test of proportions) were conducted to compare, by selected socio-demographic and sentinel injury-related characteristics, the proportion of Māori and non-Māori participants who self-reported a SUBS-Inj at their 12-month interview but had no ACC claim recorded in the period between their 3- and 12-month interviews. Variables of interest included participants’ occupation and adequacy of household income prior to sentinel injury. This information was obtained during the first POIS interview using questions from the 2006 New Zealand Census[[27]] and 2006/2007 Household Economic Survey[[28]] respectively. Level of socio-economic deprivation, based on the New Zealand Index of Deprivation 2006 (NZDep06),[[29]] severity of the sentinel injury, as measured by the New Injury Severity Score (NISS),[[30]] whether or not participants had trouble accessing healthcare for their sentinel injury (Yes: yes/mixed; No: no) and experience of treatment for this injury (Good: very good/good; Not good: moderate/bad/very bad) were also examined.

Finally, Two-Sample t-Tests of proportions were used to compare the percentage of Māori and non-Māori ACC claims that covered various injury treatments and support. Two-Sample Wilcoxon Rank-Sum Tests were used to compare the median amount of compensation paid by ACC for Māori and non-Māori claims for each of these. All statistical analyses were conducted using Stata v13.1.[[31]]

Results

Of the 2,208 POIS participants who completed the 12-month interview and responded to the subsequent injury question, two did not provide ethnicity information, leaving data from 2,206 participants for the current analyses (Figure 1). Just under one-fifth (18%; n=397) of these participants were Māori.

View Figure 1 & Tables 1–4.

Characteristics of the cohort

A greater proportion of Māori participants were male compared to non-Māori (Table 1). Māori participants were also younger, on average, than non-Māori. There was no difference in the distribution of sentinel injury severity or hospitalisation status for sentinel injury between Māori and non-Māori participants.

Subsequent injuries

Over one-quarter (29%) of participants self-reported a SUBS-Inj between the 3- and 12-month interviews. There was some evidence that suggested the prevalence of self-reported SUBS-Inj was higher for Māori than non-Māori (Table 2). This was also apparent in the ACC claims data, with 37% of Māori having ≥1 ACC-SUBS-Inj compared to 32% of non-Māori. A total of 943 ACC-SUBS-Inj claims were made by these 731 individuals (Figure 1). The distribution in the severity (NISS) of these SUBS-Injs resulting in an ACC claim did not differ between Māori and non-Māori and there was little evidence of a difference between the two groups in the prevalence of ACC-SUBS-Inj that resulted in entitlement claims.

Accessing ACC: Self-reported subsequent injuries and ACC-SUBS-Inj claims

Of the 636 participants who self-reported SUBS-Injs, 34% (n=219) did not have an ACC-SUBS-Inj between the 3- and 12-month interviews (Figure 1). Overall, 32% of Māori and 35% of non-Māori did not have an ACC-SUBS-Inj claim in this period (Table 3). Statistically significant differences were observed between Māori and non-Māori for sub-categories of only two of the independent variables, for which associations between key variables and this outcome were analysed. Of those in a trade or manual occupation, 34% of non-Māori with self-reported SUBS-Inj did not have an ACC-SUBS-Inj compared to 19% of Māori (p=0.03). The opposite was found for those with a sentinel injury NISS>6, where 53% of Māori with self-reported SI did not have an ACC-SI compared to 23% of non-Māori (p=0.02).

ACC compensation for subsequent injuries

The percentage of claims involving various transport and treatment-related compensation from ACC, and the median amounts received, are presented in Table 4. Of the 943 ACC-SUBS-Inj claims, 40 (4%) were not accepted by ACC and therefore are not included in the cost analyses. Absolute differences between the Māori and non-Māori cohorts in the percentage of ACC-SUBS-Inj claims covering a particular treatment or support varied by 6% or less across the categories examined. For the 190 Māori with an accepted ACC-SUBS-Inj claim, 71% had the costs of medical treatment for their injury paid by ACC compared to 65% of the 753 non-Māori with an accepted ACC-SUBS-Inj claim (p=0.1). The largest difference observed among entitlement claimants was for income compensation payments, with 84% of entitlement claims for Māori including income compensation compared to 72% of claims for non-Māori (p=0.2). Other notable differences were the proportions of claims that covered specialist consultations (Māori: 18.5%; non-Māori: 13.5%; p=0.09) and “other” treatments including dental, optometric, podiatrist, acupuncturist and pharmaceutical care (Māori: 11.1%; non-Māori: 16.3%; p=0.07).

The median amount of ACC compensation per ACC-SUBS-Inj claim was higher for Māori than non-Māori participants for six of the seven transport and treatment categories examined (Table 4). For specialist consultations, the median amount covered per claim was smaller for Māori (NZ$179) than non-Māori (NZ$201). The largest difference observed was for transport-related costs where the median amount covered per claim was NZ$46 greater for Māori than for non-Māori, but it should be noted that this only applied to a small number of participants in each cohort.

Discussion

Analyses found few significant differences between Māori and non-Māori in terms of treatment and support for SUBS-Injs compensated by ACC. While estimates suggest that SUBS-Inj (both self-reported and ACC), and ACC entitlement claims for SUBS-Inj, were more prevalent among Māori, there was insufficient evidence to indicate that these differences were statistically significant. There was weak evidence of a difference in compensation in two areas: the proportion of Māori ACC-SUBS-Inj claims receiving compensation for specialist consultations was greater than among non-Māori, while the opposite was found for “other” treatments. Potential reasons for these particular findings are unclear. There was no difference between Māori and non-Māori in the severity of ACC-SUBS-Inj sustained, and our previous research found no noticeable difference in the types of SUBS-Inj incurred between the Māori[[25]] and overall POIS cohorts[[26]] in the 24 months following their sentinel injury. However, without detailed information from participants on their SUBS-Inj, we do not know what the specific needs and support required were for Māori and non-Māori and if these differed in any way.

The two areas of difference between Māori and non-Māori were among those who reported a SUBS-Inj at the 12-month interview but made no ACC claim for a SUBS-Inj in the reference period of 3 to 12 months post-sentinel injury. Non-Māori in a trade or manual occupation who self-reported a SUBS-Inj were more likely to have no ACC-SUBS-Inj claim compared to Māori in a trade or manual occupation. Conversely, Māori with a more severe sentinel injury were more likely than non-Māori to have no ACC-SUBS-Inj claim despite self-reporting a SUBS-Inj. Again, there are no obvious explanations for these observed differences, thus we cannot rule out that these are spurious findings. Had work-related SUBS-Injs been more prevalent among non-Māori, then the greater prevalence with no ACC-SUBS-Inj could have been due to some of these individuals working at an ACC accredited organisation.[[32]] In these organisations, while an ACC form is still completed for work-related injuries, these are sent to the patient’s employer for them to administer and cover the costs of their employee’s treatment and rehabilitation. However, we have previously found no difference in the prevalence of work-related SUBS-Injs between Māori participants[[33]] and the overall cohort.[[34]] We have previously found differences between Māori and non-Māori in the prevalence of disability and problems with mobility at 12 months post-injury,[[17]] and the greatest prevalence of these outcomes is among those who had a more severe sentinel injury (i.e., NISS>6). A potential explanation for the greater absence of ACC claims among Māori who self-reported a SUBS-Inj after a more severe sentinel injury is that a greater proportion were still experiencing problems with mobility compared to non-Māori who self-reported a SUBS-Inj after a more severe sentinel injury. This may have dissuaded Māori from accessing treatment for their SUBS-Inj unless it was severe enough to impede their recovery further. This hypothesis is consistent with the understanding that Māori access fewer ACC injury and rehabilitation entitlements, particularly for less severe injuries, than non-Māori.[[13,15]]

Strengths of this study include having a cohort that sustained a broad range of injuries, in terms of both type and severity, across an array of contexts (e.g., work- and non-work-related), that did not necessarily result in hospitalisation. A particular focus was to provide relevant information about injury outcomes specifically for injured Māori. This has resulted in our study, to the best of our knowledge, comprising the largest group of an injured Indigenous population, enabling us to provide valuable insights into equity in healthcare access and treatment for SUBS-Inj between an Indigenous and non-Indigenous group. The ability to examine a wealth of longitudinal data leading up to the SUBS-Inj is a further strength, as is the ability to utilise detailed administrative data to gain further insights about access to SUBS-Inj support for every participant.

Nonetheless, this study has some limitations. While the number of Māori participants in the cohort is large in total, small numbers arise when examining differences within the cohort, and between Māori and non-Māori, across some variables of interest. A lack of statistical power may have contributed to insufficient evidence to detect a difference where a difference, in truth, exists. It also restricts our ability to conduct more complex multivariable analyses. The generalisability of our findings is also limited. Although our cohort experienced a broad array of injuries, it only includes individuals who had already accessed ACC support for an injury serious enough to warrant an entitlement claim. We still lack a detailed understanding of differences in access to initial treatment and support between Māori and non-Māori for injuries among the entire New Zealand population (i.e., including for those who did not access ACC support). Given ACC is a universal no-fault government-funded scheme, it is important that barriers to access for all injured Māori are better understood and addressed.

Our estimates of self-reported SUBS-Inj may be affected by measurement error (i.e., variation among participants as to what constitutes an injury), recall bias and attrition, but there is a dearth of evidence on which to judge the likelihood and extent of each, and how it may specifically impact our findings. We have no reason to believe the distribution of measurement error would differ between Māori and non-Māori and thus increase or decrease the differences observed in no ACC-SUBS-Inj claims following self-reported SUBS-Inj. The same is true for recall error. While there is some evidence to suggest that injury type and severity may affect recall,[[35]] we have previously found no substantial differences in the types of sentinel injuries sustained between Māori participants and the overall cohort, including those that might directly affect recall (e.g., intracranial injuries).[[25,26]] The severity of SUBS-Inj in this study also did not differ between Māori and non-Māori. An analysis of non-participation at the 12-month interview among the cohort found that males, younger participants and Māori were less likely to take part in this phase of POIS.[[36]] However, none of these factors (i.e., sex, age or ethnicity) were predictive of self-reporting a SUBS-Inj at the 12-months post-sentinel injury interview.[[23]]

Conclusions

Our findings provide for cautious optimism and support calls for stronger efforts to reduce barriers to accessing quality healthcare and support services for injured Māori. Subject to the limitations of our study outlined above, it appears that for those who have already accessed the ACC system—in this case, those who have received an entitlement claim—Māori and non-Māori generally received equitable compensation for SUBS-Inj. This is in terms of the percentage of accepted ACC-SUBS-Inj claims covering costs across each of the various treatment types, the percentage covering transport costs related to injury recovery and the average amount of compensation for each of these treatment and support categories. However, receiving ACC compensation for such services is only part of the story, especially in light of ACC’s Aide Memoire of May 2021 stating that Māori are less likely to benefit from the ACC scheme and are less likely to be referred for some specific treatment interventions than non-Māori.[[15]] Further research is required to determine if Māori and non-Māori are receiving equitable access and appropriate treatment for injuries regardless of injury type (i.e., sentinel or subsequent) or ACC claim type (e.g., medical fees only or entitlement claims) once entered into the health system. This study highlights two areas that warrant further attention in this regard: differences between Māori and non-Māori in the median amounts of ACC-SUBS-Inj costs for specialist consultations and “other” treatments. Are these differences, in truth, significant and, if so, why do they exist? Given Māori and non-Māori participants experienced subsequent injuries of similar types and severity, it would be concerning, for example, if Māori were not being referred to other health providers or receiving compensation for care that could further optimise their recovery (e.g., dental and/or pharmaceutical care). More detailed information on the specific needs of those injured is necessary. If the support required for subsequent injuries in truth differed between Māori and non-Māori, then similar levels of compensation would mean inequitable support relative to need. Ultimately, if New Zealand is to achieve a situation where no inequities exist between injured Māori and non-Māori, and for increased positive outcomes to be achieved for Māori, it is imperative to establish routine systems for collecting data about needs, treatment pathways and outcomes.

Summary

Abstract

Aim

To examine if differences exist between injured Māori and non-Māori in accessing and receiving support from the Accident Compensation Corporation (ACC) for treatment and rehabilitation of subsequent injuries.

Method

This cohort study utilised participants’ self-reported datafrom the Prospective Outcomes of Injury Study, and ACC claims data.

Results

Approximately one-third of Māori (32%) and non-Māori (35%)who self-reported a subsequent injury had no associated ACC claim. Statistically significant differences in this outcome (i.e., self-reported subsequent injury but no ACC claim) were found between Māori and non-Māori when comparing across occupation type and severity of participants’ sentinel injuries. Few differences were observed between Māori and non-Māori in the percentages of ACC claims accepted that compensated various treatments and supports; this was similar for average compensation amounts provided.

Conclusion

Māori and non-Māori who received support from ACC for a sentinel injury prior to sustaining another injury appear to have received equitable ACC compensation for the treatment and rehabilitation of the subsequent injury with two potential exceptions. Further research is needed to determine how generalisable these findings are. Establishing routine systems for collecting data about the support needed, treatment pathways and outcomes once accessing ACC support is vital to ensure positive and equitable injury outcomes for Māori.

Author Information

Emma H Wyeth: Associate Professor, Te Roopū Rakahau Hauora Māori a Kāi Tahu (Ngāi Tahu Māori Health Research Unit), University of Otago, Dunedin, New Zealand. Gabrielle Davie: Associate Professor, Injury Prevention Research Unit, Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand. Brett Maclennan: Senior Research Fellow, Te Roopū Rakahau Hauora Māori a Kāi Tahu (Ngāi Tahu Māori Health Research Unit), University of Otago, Dunedin, New Zealand. Michelle Lambert: Research Fellow, Te Roopū Rakahau Hauora Māori a Kāi Tahu (Ngāi Tahu Māori Health Research Unit), University of Otago, Dunedin, New Zealand. Helen Harcombe: Senior Lecturer, Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand. Trudy Sullivan: Associate Professor, Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand. Sarah Derrett: Professor, Te Roopū Rakahau Hauora Māori a Kāi Tahu (Ngāi Tahu Māori Health Research Unit), University of Otago, Dunedin, New Zealand.

Acknowledgements

The authors are grateful to the study participants for sharing their information with the research team and to the POIS interviewers for their role in collecting participant data. The study was funded by the Health Research Council of New Zealand (Project Grant 15/091).

Correspondence

Associate Professor Emma Wyeth: Te Roopū Rakahau Hauora Māori a Kāi Tahu (Ngāi Tahu Māori Health Research Unit) University of Otago, PO Box 56, Dunedin 9054, New Zealand.

Correspondence Email

emma.wyeth@otago.ac.nz

Competing Interests

Nil.

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Māori, New Zealand’s Indigenous population, experience lower rates of healthcare access and quality of care than non-Māori.[[1–5]] Treatment costs,[[1,2,5]] limited transport availability to health services[[1,5]] and other obstacles to attending appointments (e.g., no sick leave, availability of childcare)[[1,2,5]] are some of the barriers Māori face in accessing healthcare. Studies also reveal that Māori experience greater levels of racism and inappropriate care when they do present for treatment.[[6–9]] This, combined with poor communication from clinicians,[[1,2,10]] and a dearth of culturally safe health providers, can result in Māori disengaging from healthcare services or delaying seeking treatment,[[6,10,11]] likely contributing to why Māori have lower rates of access to services and support provided by the Accident Compensation Corporation (ACC), New Zealand’s universal no-fault injury insurer. Lodgement of claims for ACC support are made by health service providers on behalf of patients who present for treatment of an injury.[[12]]

ACC have long acknowledged that Māori have not benefited from their services to the same extent that non-Māori have, receiving ACC-funded support and entitlements at a lower rate than non-Māori.[[13,14]] An ACC Aide Memoir,[[15]] provided to the New Zealand Government’s Minister of ACC in May 2021 and obtained via an Official Information Act request, revealed that Māori are more likely to experience serious injuries, are less likely to lodge claims for non-serious injuries, and, alarmingly, are less likely to be referred for certain injury treatment interventions than non-Māori claimants.[[15]] This is consistent with other research that has found Māori experience lower quality of care in terms of less optimal treatment pathways and lower rates of referral to specialist treatment than non-Māori.[[2-4]] It may also help explain why Māori experience a greater prevalence of adverse injury outcomes than non-Māori,[[16]] even when having accessed ACC support.[[17,18]]

These experiences could have significant consequences when it comes to seeking treatment and support from ACC for subsequent injuries (SUBS-Inj), i.e., injuries that occur after, but not necessarily due to, an earlier “initial” (sentinel) injury. Subsequent injuries can be more costly financially and socially, and have greater consequences in terms of disability, than initial (sentinel) injuries.[[19–21]] Differential rates in accessing and receiving treatment and ACC support for SUBS-Inj could exacerbate the already concerning inequities in adverse injury outcomes between Māori and non-Māori. Therefore, the overall aim of this study was to investigate whether there were differences between Māori and non-Māori in claims made to ACC for SUBS-Inj, and compensation received, among a population who had already sustained a significant injury no more than 12 months earlier.

The Prospective Outcomes of Injury Study (POIS)[[22]] is a longitudinal study of people aged 18–64 years who sustained an injury warranting an ACC entitlement claim (i.e., earnings-related compensation, home help and/or travel assistance) between 2007–2009. Participants were interviewed, on average, 3, 12 and 24 months following their sentinel injury (i.e., the injury that led to their recruitment to the study). Nearly one-third (32%) of Māori compared to 28% of NZ Europeans self-reported sustaining a SUBS-Inj between 3 and 12 months after their sentinel injury.[[23]] The Subsequent Injury Study (SInS)[[24]] utilised ACC administrative data and found that 42% of Māori participants experienced at least one SUBS-Inj involving an ACC claim (ACC-SUBS-Inj) in the 12 months following their sentinel injury.[[25]] The prevalence in the total cohort was 38%.[[26]]

Utilising data obtained from POIS participants and administrative data obtained from the ACC, descriptive analyses were conducted to compare the following between Māori and non-Māori: 1) the proportion of participants who self-reported a SUBS-Inj between 3 and 12 months after their sentinel injury but who did not have a corresponding ACC claim for a SUBS-Inj (ACC-SUBS-Inj) during this period (including comparisons by socio-demographic variables and experiences of healthcare for their sentinel injury), 2) the severity of ACC-SUBS-Inj and the proportion that resulted in an entitlement claim, and 3) the percentage of ACC-SUBS-Inj claims that covered various treatments and supports, and the median amount of compensation provided by ACC. The analyses presented in this paper provide original findings to contribute to the limited evidence base about equity between Māori and non-Māori in terms of accessing and receiving ACC support for subsequent injuries, for those that have already received treatment and support from ACC for an earlier injury.

Methods

POIS participants were asked about their injury and recovery during interviews conducted primarily by telephone. Details explaining the recruitment of individuals and the collection of data have been published elsewhere.[[22]] Ethical approval for this study was obtained from the New Zealand Health and Disability Multi-Region Ethics Committee (MEC/07/07/093).

At the 12-month POIS interview, participants were asked: “Since we last spoke about 8 months ago, have you had any other (new) injuries? That is, injuries that have occurred as the result of a separate incident from the original injury.” These included injuries of any type or anatomical site. For the 12-month period following their sentinel injury, ACC injury compensation claims data inclusive of all claim types (i.e., not just entitlement claims) were obtained for all POIS participants (data received from ACC in 2013). The reference period for self-reported SUBS-Inj was between the 3- and 12-month interviews (following the sentinel injury). The ACC claims data about SUBS-Inj used in this study was selected to correspond to that same period.

Chi-squared tests were conducted to compare the socio-demographic and injury-related characteristics (of both sentinel and SUBS-Inj) between Māori and non-Māori participants. Ethnicity information was collected at each POIS interview using the 2006 New Zealand Census ethnicity question.[[27]] Māori participants were those who reported Māori ethnicity at either of the interviews, regardless of additional ethnicities they may have also reported.

Equality of proportions tests (Two-Sample t-Test of proportions) were conducted to compare, by selected socio-demographic and sentinel injury-related characteristics, the proportion of Māori and non-Māori participants who self-reported a SUBS-Inj at their 12-month interview but had no ACC claim recorded in the period between their 3- and 12-month interviews. Variables of interest included participants’ occupation and adequacy of household income prior to sentinel injury. This information was obtained during the first POIS interview using questions from the 2006 New Zealand Census[[27]] and 2006/2007 Household Economic Survey[[28]] respectively. Level of socio-economic deprivation, based on the New Zealand Index of Deprivation 2006 (NZDep06),[[29]] severity of the sentinel injury, as measured by the New Injury Severity Score (NISS),[[30]] whether or not participants had trouble accessing healthcare for their sentinel injury (Yes: yes/mixed; No: no) and experience of treatment for this injury (Good: very good/good; Not good: moderate/bad/very bad) were also examined.

Finally, Two-Sample t-Tests of proportions were used to compare the percentage of Māori and non-Māori ACC claims that covered various injury treatments and support. Two-Sample Wilcoxon Rank-Sum Tests were used to compare the median amount of compensation paid by ACC for Māori and non-Māori claims for each of these. All statistical analyses were conducted using Stata v13.1.[[31]]

Results

Of the 2,208 POIS participants who completed the 12-month interview and responded to the subsequent injury question, two did not provide ethnicity information, leaving data from 2,206 participants for the current analyses (Figure 1). Just under one-fifth (18%; n=397) of these participants were Māori.

View Figure 1 & Tables 1–4.

Characteristics of the cohort

A greater proportion of Māori participants were male compared to non-Māori (Table 1). Māori participants were also younger, on average, than non-Māori. There was no difference in the distribution of sentinel injury severity or hospitalisation status for sentinel injury between Māori and non-Māori participants.

Subsequent injuries

Over one-quarter (29%) of participants self-reported a SUBS-Inj between the 3- and 12-month interviews. There was some evidence that suggested the prevalence of self-reported SUBS-Inj was higher for Māori than non-Māori (Table 2). This was also apparent in the ACC claims data, with 37% of Māori having ≥1 ACC-SUBS-Inj compared to 32% of non-Māori. A total of 943 ACC-SUBS-Inj claims were made by these 731 individuals (Figure 1). The distribution in the severity (NISS) of these SUBS-Injs resulting in an ACC claim did not differ between Māori and non-Māori and there was little evidence of a difference between the two groups in the prevalence of ACC-SUBS-Inj that resulted in entitlement claims.

Accessing ACC: Self-reported subsequent injuries and ACC-SUBS-Inj claims

Of the 636 participants who self-reported SUBS-Injs, 34% (n=219) did not have an ACC-SUBS-Inj between the 3- and 12-month interviews (Figure 1). Overall, 32% of Māori and 35% of non-Māori did not have an ACC-SUBS-Inj claim in this period (Table 3). Statistically significant differences were observed between Māori and non-Māori for sub-categories of only two of the independent variables, for which associations between key variables and this outcome were analysed. Of those in a trade or manual occupation, 34% of non-Māori with self-reported SUBS-Inj did not have an ACC-SUBS-Inj compared to 19% of Māori (p=0.03). The opposite was found for those with a sentinel injury NISS>6, where 53% of Māori with self-reported SI did not have an ACC-SI compared to 23% of non-Māori (p=0.02).

ACC compensation for subsequent injuries

The percentage of claims involving various transport and treatment-related compensation from ACC, and the median amounts received, are presented in Table 4. Of the 943 ACC-SUBS-Inj claims, 40 (4%) were not accepted by ACC and therefore are not included in the cost analyses. Absolute differences between the Māori and non-Māori cohorts in the percentage of ACC-SUBS-Inj claims covering a particular treatment or support varied by 6% or less across the categories examined. For the 190 Māori with an accepted ACC-SUBS-Inj claim, 71% had the costs of medical treatment for their injury paid by ACC compared to 65% of the 753 non-Māori with an accepted ACC-SUBS-Inj claim (p=0.1). The largest difference observed among entitlement claimants was for income compensation payments, with 84% of entitlement claims for Māori including income compensation compared to 72% of claims for non-Māori (p=0.2). Other notable differences were the proportions of claims that covered specialist consultations (Māori: 18.5%; non-Māori: 13.5%; p=0.09) and “other” treatments including dental, optometric, podiatrist, acupuncturist and pharmaceutical care (Māori: 11.1%; non-Māori: 16.3%; p=0.07).

The median amount of ACC compensation per ACC-SUBS-Inj claim was higher for Māori than non-Māori participants for six of the seven transport and treatment categories examined (Table 4). For specialist consultations, the median amount covered per claim was smaller for Māori (NZ$179) than non-Māori (NZ$201). The largest difference observed was for transport-related costs where the median amount covered per claim was NZ$46 greater for Māori than for non-Māori, but it should be noted that this only applied to a small number of participants in each cohort.

Discussion

Analyses found few significant differences between Māori and non-Māori in terms of treatment and support for SUBS-Injs compensated by ACC. While estimates suggest that SUBS-Inj (both self-reported and ACC), and ACC entitlement claims for SUBS-Inj, were more prevalent among Māori, there was insufficient evidence to indicate that these differences were statistically significant. There was weak evidence of a difference in compensation in two areas: the proportion of Māori ACC-SUBS-Inj claims receiving compensation for specialist consultations was greater than among non-Māori, while the opposite was found for “other” treatments. Potential reasons for these particular findings are unclear. There was no difference between Māori and non-Māori in the severity of ACC-SUBS-Inj sustained, and our previous research found no noticeable difference in the types of SUBS-Inj incurred between the Māori[[25]] and overall POIS cohorts[[26]] in the 24 months following their sentinel injury. However, without detailed information from participants on their SUBS-Inj, we do not know what the specific needs and support required were for Māori and non-Māori and if these differed in any way.

The two areas of difference between Māori and non-Māori were among those who reported a SUBS-Inj at the 12-month interview but made no ACC claim for a SUBS-Inj in the reference period of 3 to 12 months post-sentinel injury. Non-Māori in a trade or manual occupation who self-reported a SUBS-Inj were more likely to have no ACC-SUBS-Inj claim compared to Māori in a trade or manual occupation. Conversely, Māori with a more severe sentinel injury were more likely than non-Māori to have no ACC-SUBS-Inj claim despite self-reporting a SUBS-Inj. Again, there are no obvious explanations for these observed differences, thus we cannot rule out that these are spurious findings. Had work-related SUBS-Injs been more prevalent among non-Māori, then the greater prevalence with no ACC-SUBS-Inj could have been due to some of these individuals working at an ACC accredited organisation.[[32]] In these organisations, while an ACC form is still completed for work-related injuries, these are sent to the patient’s employer for them to administer and cover the costs of their employee’s treatment and rehabilitation. However, we have previously found no difference in the prevalence of work-related SUBS-Injs between Māori participants[[33]] and the overall cohort.[[34]] We have previously found differences between Māori and non-Māori in the prevalence of disability and problems with mobility at 12 months post-injury,[[17]] and the greatest prevalence of these outcomes is among those who had a more severe sentinel injury (i.e., NISS>6). A potential explanation for the greater absence of ACC claims among Māori who self-reported a SUBS-Inj after a more severe sentinel injury is that a greater proportion were still experiencing problems with mobility compared to non-Māori who self-reported a SUBS-Inj after a more severe sentinel injury. This may have dissuaded Māori from accessing treatment for their SUBS-Inj unless it was severe enough to impede their recovery further. This hypothesis is consistent with the understanding that Māori access fewer ACC injury and rehabilitation entitlements, particularly for less severe injuries, than non-Māori.[[13,15]]

Strengths of this study include having a cohort that sustained a broad range of injuries, in terms of both type and severity, across an array of contexts (e.g., work- and non-work-related), that did not necessarily result in hospitalisation. A particular focus was to provide relevant information about injury outcomes specifically for injured Māori. This has resulted in our study, to the best of our knowledge, comprising the largest group of an injured Indigenous population, enabling us to provide valuable insights into equity in healthcare access and treatment for SUBS-Inj between an Indigenous and non-Indigenous group. The ability to examine a wealth of longitudinal data leading up to the SUBS-Inj is a further strength, as is the ability to utilise detailed administrative data to gain further insights about access to SUBS-Inj support for every participant.

Nonetheless, this study has some limitations. While the number of Māori participants in the cohort is large in total, small numbers arise when examining differences within the cohort, and between Māori and non-Māori, across some variables of interest. A lack of statistical power may have contributed to insufficient evidence to detect a difference where a difference, in truth, exists. It also restricts our ability to conduct more complex multivariable analyses. The generalisability of our findings is also limited. Although our cohort experienced a broad array of injuries, it only includes individuals who had already accessed ACC support for an injury serious enough to warrant an entitlement claim. We still lack a detailed understanding of differences in access to initial treatment and support between Māori and non-Māori for injuries among the entire New Zealand population (i.e., including for those who did not access ACC support). Given ACC is a universal no-fault government-funded scheme, it is important that barriers to access for all injured Māori are better understood and addressed.

Our estimates of self-reported SUBS-Inj may be affected by measurement error (i.e., variation among participants as to what constitutes an injury), recall bias and attrition, but there is a dearth of evidence on which to judge the likelihood and extent of each, and how it may specifically impact our findings. We have no reason to believe the distribution of measurement error would differ between Māori and non-Māori and thus increase or decrease the differences observed in no ACC-SUBS-Inj claims following self-reported SUBS-Inj. The same is true for recall error. While there is some evidence to suggest that injury type and severity may affect recall,[[35]] we have previously found no substantial differences in the types of sentinel injuries sustained between Māori participants and the overall cohort, including those that might directly affect recall (e.g., intracranial injuries).[[25,26]] The severity of SUBS-Inj in this study also did not differ between Māori and non-Māori. An analysis of non-participation at the 12-month interview among the cohort found that males, younger participants and Māori were less likely to take part in this phase of POIS.[[36]] However, none of these factors (i.e., sex, age or ethnicity) were predictive of self-reporting a SUBS-Inj at the 12-months post-sentinel injury interview.[[23]]

Conclusions

Our findings provide for cautious optimism and support calls for stronger efforts to reduce barriers to accessing quality healthcare and support services for injured Māori. Subject to the limitations of our study outlined above, it appears that for those who have already accessed the ACC system—in this case, those who have received an entitlement claim—Māori and non-Māori generally received equitable compensation for SUBS-Inj. This is in terms of the percentage of accepted ACC-SUBS-Inj claims covering costs across each of the various treatment types, the percentage covering transport costs related to injury recovery and the average amount of compensation for each of these treatment and support categories. However, receiving ACC compensation for such services is only part of the story, especially in light of ACC’s Aide Memoire of May 2021 stating that Māori are less likely to benefit from the ACC scheme and are less likely to be referred for some specific treatment interventions than non-Māori.[[15]] Further research is required to determine if Māori and non-Māori are receiving equitable access and appropriate treatment for injuries regardless of injury type (i.e., sentinel or subsequent) or ACC claim type (e.g., medical fees only or entitlement claims) once entered into the health system. This study highlights two areas that warrant further attention in this regard: differences between Māori and non-Māori in the median amounts of ACC-SUBS-Inj costs for specialist consultations and “other” treatments. Are these differences, in truth, significant and, if so, why do they exist? Given Māori and non-Māori participants experienced subsequent injuries of similar types and severity, it would be concerning, for example, if Māori were not being referred to other health providers or receiving compensation for care that could further optimise their recovery (e.g., dental and/or pharmaceutical care). More detailed information on the specific needs of those injured is necessary. If the support required for subsequent injuries in truth differed between Māori and non-Māori, then similar levels of compensation would mean inequitable support relative to need. Ultimately, if New Zealand is to achieve a situation where no inequities exist between injured Māori and non-Māori, and for increased positive outcomes to be achieved for Māori, it is imperative to establish routine systems for collecting data about needs, treatment pathways and outcomes.

Summary

Abstract

Aim

To examine if differences exist between injured Māori and non-Māori in accessing and receiving support from the Accident Compensation Corporation (ACC) for treatment and rehabilitation of subsequent injuries.

Method

This cohort study utilised participants’ self-reported datafrom the Prospective Outcomes of Injury Study, and ACC claims data.

Results

Approximately one-third of Māori (32%) and non-Māori (35%)who self-reported a subsequent injury had no associated ACC claim. Statistically significant differences in this outcome (i.e., self-reported subsequent injury but no ACC claim) were found between Māori and non-Māori when comparing across occupation type and severity of participants’ sentinel injuries. Few differences were observed between Māori and non-Māori in the percentages of ACC claims accepted that compensated various treatments and supports; this was similar for average compensation amounts provided.

Conclusion

Māori and non-Māori who received support from ACC for a sentinel injury prior to sustaining another injury appear to have received equitable ACC compensation for the treatment and rehabilitation of the subsequent injury with two potential exceptions. Further research is needed to determine how generalisable these findings are. Establishing routine systems for collecting data about the support needed, treatment pathways and outcomes once accessing ACC support is vital to ensure positive and equitable injury outcomes for Māori.

Author Information

Emma H Wyeth: Associate Professor, Te Roopū Rakahau Hauora Māori a Kāi Tahu (Ngāi Tahu Māori Health Research Unit), University of Otago, Dunedin, New Zealand. Gabrielle Davie: Associate Professor, Injury Prevention Research Unit, Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand. Brett Maclennan: Senior Research Fellow, Te Roopū Rakahau Hauora Māori a Kāi Tahu (Ngāi Tahu Māori Health Research Unit), University of Otago, Dunedin, New Zealand. Michelle Lambert: Research Fellow, Te Roopū Rakahau Hauora Māori a Kāi Tahu (Ngāi Tahu Māori Health Research Unit), University of Otago, Dunedin, New Zealand. Helen Harcombe: Senior Lecturer, Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand. Trudy Sullivan: Associate Professor, Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand. Sarah Derrett: Professor, Te Roopū Rakahau Hauora Māori a Kāi Tahu (Ngāi Tahu Māori Health Research Unit), University of Otago, Dunedin, New Zealand.

Acknowledgements

The authors are grateful to the study participants for sharing their information with the research team and to the POIS interviewers for their role in collecting participant data. The study was funded by the Health Research Council of New Zealand (Project Grant 15/091).

Correspondence

Associate Professor Emma Wyeth: Te Roopū Rakahau Hauora Māori a Kāi Tahu (Ngāi Tahu Māori Health Research Unit) University of Otago, PO Box 56, Dunedin 9054, New Zealand.

Correspondence Email

emma.wyeth@otago.ac.nz

Competing Interests

Nil.

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